This week I've opted for a slightly longer format, which I sometimes like to do—we'll be back to normal next time. Enjoy.
On Friday December 13th, 1799, President George Washington was in a chipper mood. He sat by the fire talking politics with Martha and Tobias Lear, his secretary. At age 67, two years after his presidency, Washington was still America’s most popular public figure. Robustly healthy, he had spent the afternoon on his Mount Vernon estate marking trees through a snowfall. Now, however, he mentioned a sore throat that had been dogging him for days. Lear noted the President was hoarse, and suggested medicine. Forever the stoic soldier, Washington declined. “Let it go as it came," he said.
Among medical historians the infection that ended Washington’s life the next day is a subject of debate. All agree, however, on the nature of his care. The physicians who worked furiously at his side were highly trained, deeply concerned—and fully culpable.
In the early morning hours Martha woke to find the President in pain and short of breath. Washington insisted she wait til light to summon help, lest she be exposed to the night air. At sunrise Martha notified Lear, and messengers were dispatched for James Craik, a local physician and dear friend. While awaiting Craik’s arrival Washington summoned the overseer of the estate, Albin Rawlins, to perform a bleeding. Bloodletting, to remove toxins and restore balance, was routine in such illnesses. Rawlins incised a vein in the President’s inner forearm, and 14 ounces of blood flowed. Martha, suspicious of bloodletting, voiced her discomfort. But Washington encouraged it. "Don't be afraid. The orifice is not large enough. More, more."
Dr. James Craik, who fought at Washington’s side in the Revolutionary War, arrived late in the morning. Craik was a former Physician General, similar to today’s Surgeon General, and attended the University of Edinburgh in Scotland, widely considered the world’s most respected training ground. The President had recently convinced Craik to move his practice nearby, and he arrived to find Washington with severe throat swelling and a fever. Craik began treatment with a blister of Cantharides on the President’s neck. The powdered beetle preparation was intended to purge toxins by raising a blister on the skin, which it did.
Washington’s condition, however, worsened. Craik performed the morning’s second bleeding. This time he drained 20 ounces, again from the General’s arm.
As noonday passed the President’s breathing became labored. Attempts to swallow, including a concoction of molasses, vinegar, and butter, resulted in violent coughing spasms. The President’s throat appeared to be closing. Craik administered doses of calomel and tartar rectally. Calomel, a mercury-based pesticide, functioned as a purgative to stimulate bowel evacuation. Tartar, another common pesticide, produced vomiting. Both were believed to remove toxins. The president moved his bowels and retched. But he did not improve.
Concerned, Craik bled him again, for 20 more ounces.
In the late afternoon Dr.'s Elisha Cullen Dick and Gustavus Brown arrived to find Washington gravely ill and barely able to speak. Dick was a prominent young doctor who had earned his degree from the University of Pennsylvania. Dr. Brown, a lifelong friend of the President and Surgeon General of the Continental Army in the Revolution, had also trained at Edinburgh. After conferring, the physicians reached a consensus and acted.
They spilled 40 more ounces of the president's blood, for a total of 94. So far.
The first president of the United States, a young country’s most beloved figure, was slipping away. The three physicians conferred again and quickened their pace. Blisters on the arms, inhaled vapors, cataplasms (a form of compress) for the skin, more purgatives. Nothing was helping, and Washington’s throat was now almost fully occluded.
The doctors were frantic, but the President was not. According to Tobias Lear, the great general asked them to cease their efforts. “I thank you for your attentions, but I pray you take no more troubles about me” he whispered. “Let me go off quietly.”
Dr. Dick, the youngest and brashest of the three, suggested they perforate Washington’s trachea. It was a last resort and Dick understood the implications, offering to take responsibility for any untoward outcome. Surgically opening an airway—tracheostomy—was new. Twenty-five years later the French surgeon Armand Trousseau would use the technique to save children suffocating from diphtheria, allowing them to survive an infection whose only fatal mechanism was airway closure. Dr. Dick felt asphyxiation was the President’s greatest threat. Still, tracheostomy was experimental and new. The older physicians would not assent.
Instead, they offered a final effort: 32 more ounces of presidential blood.
Just after 10pm the President spoke his final words, “‘Tis well”, and checked his own pulse. As one witness recalled “With surprising self-possession he prepared to die. Composing his form at length and folding his arms on his bosom, without a sigh, without a groan, the Father of his Country died. “
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To the modern mind, the events of Washington’s death are unfathomable. Basic principles of medicine and common sense seem grievously violated. But all three of Washington’s physicians trained at leading universities, and had the purest of intentions. Two were close friends and all were aware of the President’s god-like status. Yet incredibly, they took a gallon of his blood. Even for a man of the President’s stature (over 6 feet, more than 200 lbs.) this was nearly two thirds his total blood volume.
Could it be the importance of human blood was unknown in 1799? More than a century earlier William Harvey elucidated the mechanics of a beating heart, and the blood it propels. And despite a confused understanding, blood was known to be necessary for survival. Two of Washington’s doctors were battlefield surgeons who had witnessed, and attempted to stanch, mortal blood loss. What, then, explains the quasi-assassination?
Experiential delusion and ideologic gumption.
For Hippocrates the delusion of experience plagued the practice of medicine, which he called 'the Art'. In his best-known aphorism Hippocrates wrote, “Life is short, the Art is long, opportunity fleeting, experience delusive, judgment difficult.” With bloodletting, the delusion was powerful. Even in the 18th century, while bloodletting harmed the chance of survival (as controlled experiments later showed) most people still recovered soon after, creating the illusion of effectiveness.
And Dr.’s Craik, Brown, and Dick were accomplished bleeders. With years of practice and thousands of anecdotes, all three were fully deluded. Of course, none subjected their knowledge to rigorous testing. None compared notes with physicians who did not use bleeding. And none conducted—or had likely ever heard of—a randomized trial.
Experiential delusion can be all-consuming. But a second, equally powerful trap was in play at Mount Vernon. In 1799 the Humoral Theory of illness was the prevailing ideology at top medical schools and universities. A vestige of the ancient Greeks' four humors (blood, phlegm, yellow bile, black bile) the theory centered on toxins and a belief in 'balance'. To heal, doctors were taught to restore balance by removing toxins. Dr. Craik began with a blister of Cantharides which created a skin eruption, a visual sign that evil toxins were erupting forth. The tartar and calomel, designed to wreak intestinal havoc by inducing diarrhea and vomiting, provided two more routes of egress for toxins. Indeed, all the methods used on the president—cataplasms, vapors, purgatives, suppositories, blisters, salves, and bleedings—were for purging toxins.
Washington’s doctors stuck to the ideological script they were given. Neither their experiences in war, nor recent papers challenging bloodletting, not even their friend’s death spiral, could make them deviate from their faith. When bloodletting made Washington worse, they doubled down. Even for honest, rational men, ideologic gumption overwhelmed both the sciences and the senses.
Experiential delusion eschews scientific method and handicaps reasoning, teaching the opposite of truth. Ideologic gumption consecrates the delusion, closing the mind's eye, and setting a fixed, inalterable path. Together, the traps are a prison of wrongheadedness.
Which leads to an inevitable question: If the most experienced, best trained, brightest physicians of the day, using the most advanced theories and therapies, hastened the death of their friend, what of today? In the science-soaked 21st century are we fooled by experiential delusion? Do we suffer from ideologic gumption?
You bet.
A hundred years from now scientists will shake their heads at us. Our theories will seem primitive and our methods feeble. And for many of our errors the evidence is here, now, staring us in the face.
Today's cardiologic version of the Humoral Theory, for instance, is the Lipid Hypothesis, suggesting cholesterol is the primary cause of heart disease. First debunked by findings from the Framingham study in 1987, the Lipid Hypothesis was birthed, ironically, by earlier results in the same study. In 1961, preliminary papers from the project explored cholesterol as a potential risk factor for early death. But over time the already tenuous connection waned further, even as risk factors like high blood pressure, smoking, and diabetes grew more robust. By 30 years of follow-up low cholesterol was associated with early death, not high. Other than men under 50 with exceedingly high levels (e.g. those caused by rare conditions like familial hypercholesterolemia) 'high' cholesterol was meaningless.
Many modern, arguably more rigorous studies have confirmed the final Framingham findings, and they often include figures like the one below, plotting mortality against cholesterol levels.
The solid pink line is mortality, plotted against LDL cholesterol in US adults between 1999 and 2014. The thin black line (at 1.0 on the y-axis) represents the expected mortality rate. Keeping in mind that high cholesterol is defined as an LDL over 130, note that mortality does not begin to rise until the number reaches 200 or more—a level rarely found in adults. Conversely, when LDL dips below 120 mortality starts rising and takes a sharp upward turn at <90, with a death risk far outpacing anything on the high end of the LDL curve.
If Martians came to earth today and saw these data they would find it utterly baffling, and existentially suicidal, for humans to routinely take drugs that aim to place cholesterol levels at the steepest, most dangerous part of the death curve. They would be equally confused by any notion of attempting to lower cholesterol, other than in people with rare, ultra-high LDL levels.
With millions prescribed statins, and the ongoing pursuit of ever lower cholesterol, we are witnessing experiential delusion and ideologic gumption in full flower. Drugs satisfy and delight by lowering cholesterol (think: draining blood)—and most who take them survive. The delusion grows with every prescription, and the ideological thirst is quenched as cholesterol levels drop.
The two logic traps have led to thinking on cholesterol that is hard to understand as anything other than delusional. This week's New England Journal of Medicine includes a paper suggesting children should be on life-long, preventive statin drugs—despite no study ever showing cholesterol reduction in children is even safe, much less effective for preventing heart problems.
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In the days following Washington's death, Dr. Brown sent a letter to his friend James Craik. Among other regrets, of young Dr. Dick, Brown confessed "I have often thought if we had acted according to his suggestion when he said, 'He needs all his strength—bleeding will diminish it,' and taken no more blood from him, our good friend might have been alive now."
As the Lipid Hypothesis continues to unravel, might cardiologists engage in the kind of soul-searching in Brown’s letters? When, as one truth-teller recently asked, will the cholesterol reckoning begin?
Most likely, never. As cholesterol's impotence becomes increasingly clear it is far more likely the demand side of the supply curve will change. If so, the Lipid Hypothesis will die a slow, quiet death. Educated patients will refuse the drugs, media will question the diets, and pharmaceutical companies will shift their gaze in search of new, shinier targets. The conventional wisdom will adjust, and disordered thinking will resume, most likely with a new, equally delusional focus.
Unfortunately, ideologic gumption and experiential delusion are stubborn traps that rarely lead to mea culpas or recantations. Brown concluded his otherwise reflective note with a defense that reads like the final half-woof of a chastened dog: "But we were governed by the best light we had; we thought we were right, and so we are justified."
Sorry, Dr. Brown. That is not how history sees it.
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